Provider Demographics
NPI:1043806482
Name:MORENO, FAUSTINO CRUZ (CPHT)
Entity Type:Individual
Prefix:
First Name:FAUSTINO
Middle Name:CRUZ
Last Name:MORENO
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 POINT WEST ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78224-2230
Mailing Address - Country:US
Mailing Address - Phone:726-205-3717
Mailing Address - Fax:
Practice Address - Street 1:6877 SEBASTOPOL AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3416
Practice Address - Country:US
Practice Address - Phone:707-823-7209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-20
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30127414183700000X
TX239328183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty